Provider Demographics
NPI:1093762361
Name:MARY IMMACULATE HOSPITAL
Entity Type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-886-6758
Mailing Address - Street 1:2 BERNARDINE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4404
Mailing Address - Country:US
Mailing Address - Phone:757-886-6000
Mailing Address - Fax:757-886-6069
Practice Address - Street 1:2 BERNARDINE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4404
Practice Address - Country:US
Practice Address - Phone:757-886-6000
Practice Address - Fax:757-886-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty